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SAN JOAQUIN COUNTY <br /> ENVfRQtJfV1EIVTAL HEALTH DEPARTMENT � D rn this form by the <br /> ;'. 600 East Main Street,Stockton,CA 95202-3029 1 of each month <br /> `- Telephone:(209)468-3420 Fax:(205)454-0135 Web:wvrw.sj,ay.orgIehd <br /> SEPTAGE CLE NER'S REPORT <br /> ID"� +4 FF <br /> Company Name: � �(�� ] Report fo a man#h of: � year 4 <br /> m Company Address: - g gea�re; <br /> SMOX Address City Zip Coda <br /> m All information submitted must be complete, accurate and legible <br /> fV <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESME7FML NAAfEE OF TREATIIIEUT <br /> PUMPED PROPERTYOWNER PUMPED (61 GREASE TRAP FACILITY <br /> i PLEASE INCLUDE STREET 9, DIRECTION, STREET NAME AND CITY G CHEMICAL <br /> cly E <br /> City <br /> ko <br /> i <br /> i <br /> 01 + C-- <br /> l9 <br /> U) <br /> city <br /> City <br /> C] <br /> Z icity <br /> x <br /> Q C� <br /> city <br /> LO ` C' <br /> w <br /> U <br /> Cfly <br /> w C. f <br /> Ln <br /> L7 CRY <br /> a <br /> � car I <br /> o ! <br /> L5 C i <br /> cr <br /> N� 4r <br /> Of <br /> O C' <br /> CE <br /> EHO 42-04 SEPTAGE CLEANERS REPORT <br /> �er�ot <br /> D <br />